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a Localized bile duct dilatation with lithiasis was confirmed after hepatic resection with the aid of indocyanine green fluorescence imaging and navigation (white arrow); b Pathology demonstrated bile duct dilatation with inflammatory cell infiltration; c Postoperative enhanced CT confirmed the integrity of the resection and the location of middle hepatic vein (MHV, red arrow)
Source publication
Background
Primary intrahepatic bile duct dilatation can be very harmful to patients although it belongs to benign biliary disease. It can occur in any part of the liver, intraoperative laparoscopic ultrasound (LUS) guidance combine with real-time indocyanine green (ICG) fluorescence navigation are the means of choice for accurate surgical resectio...
Citations
... Two different techniques for visualization of the segmental hepatic anatomy with ICG have been described. In the positive staining technique, ICG is directly injected into a segmental portal branch [25], whilst in the negative staining technique, ICG is injected intravenously after selective clamping of the segmental portal pedicle [26][27][28]. ...
Simple Summary
Surgery still represents the gold standard for the treatment of colorectal liver metastases (CRLMs); thus, accurate evaluation of the number and location of nodules is crucial in order to achieve effective oncological results. Indocyanine green fluorescence (ICG) imaging, combined with intraoperative ultrasound, was revealed to be a valid and easily reproducible tool for this purpose. This study explored the use of ICG for the detection of tiny and superficial CRLMs during minimally invasive liver resection, using the integrity of the fluorescent rim around the lesion as a marker of radical resection (R0).
Abstract
Background: The European Association of Endoscopic Surgery (EAES) recommends, with strong evidence, the use of indocyanine green (ICG) fluorescence imaging combined with intraoperative ultrasound (IOUS) to improve identification of superficial liver tumors. This study reports the use of ICG for the detection of colorectal liver metastases (CRLMs) during minimally invasive liver resection. Methods: A single-center consecutive series of minimally invasive (laparoscopic and robotic) hepatic resections for CRLMs was prospectively evaluated (April 2019 and October 2023). Results: A total of 25 patients were enrolled—11 undergoing laparoscopic and 14 undergoing robotic procedures. The median age was 65 (range 50–85) years. Fifty CRLMs were detected: twenty superficial, eight exophytic, seven shallow (<8 mm from the hepatic surface), and fifteen deep (>10 mm from the hepatic surface) lesions. The detection rates of CRLMs through preoperative imaging, laparoscopic ultrasound (LUS), ICG fluorescence, and combined modalities (ICG and LUS) were 88%, 90%, 68%, and 100%, respectively. ICG fluorescence staining allowed us to detect five small additional superficial lesions (not identified with other preoperative/intraoperative techniques). However, two lesions were false positive fluorescence accumulations. All rim fluorescence pattern lesions were CRLMs. ICG fluorescence was used as a real-time guide to assess surgical margins during parenchymal-sparing liver resections. All patients with integrity of the fluorescent rim around the CRLM displayed a radical resection during histopathological analysis. Four patients (8%) with a protruding rim or residual rim patterns had positive resection margins. Conclusions: ICG fluorescence imaging can be integrated with other conventional intraoperative imaging techniques to optimize intraoperative staging. Rim fluorescence proved to be a valid indicator of the resection margins: by removing the entire fluorescent area, a tumor-negative resection (R0) is achieved.
